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46 <br /> STATE OF CALIFORNIA .r P <br /> N' <br /> Ll� STATE WATER RESOURCES CONTROL BOARD wr , <br /> UNDERGROUND ST A TANK PERMIT APPLICATION• FOM 8 <br /> COMPLETE A SEPARATE FORM FORE TANK SYSTEM <br /> MARK ONLY F--] 1 NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTL CL E <br /> ONE ITEM F-] 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOV D <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: dl <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: <br /> C. DATE INSTALLED(M AY/YEAR) D. TANK CAPACITY IN GALLONS: <br /> II.TANKC ENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> i MOTOR VEHICLE FUEL 4 OIL B. C D taREGULARUNLEADED IESEL 6 AVIATION GAS <br /> A 2 PETROLEUM 0 80 EMPTY 1 PRODUCT 1b PREMIUM 4 GASAHOL 7 METHANOL <br /> 3 CHEMICAL PRODUCT F 95 UNKNOWN a 2 WASTE 0 2 LEADED UNLEADED 5 JET FUEL <br /> 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.# <br /> III. TANK CONSTR UCTIO F MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF 9 UBLE WALL 0 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL F-1 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 0 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F-1 5 CONCRETE F-] 6 POLYVINYL CHLORIDE F-1 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) O 9 BRONZE 0 10 GALVANIZED STEEL a 95 UNKNOWN E::] 99 OTHER <br /> 1 RUBBER LINED a 2 ALKYD LINING a 3 EPDXY LINING F-� 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING a 6 UNLINED 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO <br /> D.CORROSION F--] 1 POLYETHYLENE WRAP F-] 2 COATING ❑ 3 VINYL WRAP E:] 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F-] 5 CATHODIC PROTECTION a 91 NONE E::]95 UNKNOWN [::] 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100°/ METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U /0 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 0 1 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING ❑ 3 MONITORINGINTERSTITIAL <br /> ❑ss OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK F--j 2 INVENTORY RECONCILIATION F--j 3 VADOZE MONITORING a 4 AUTOMATIC TANK GAUGING a 5 GROUND WATER MONITORING <br /> 6 TANK TESTING F--] 7 INTERSTITIAL MONITORING F-1 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH S ' <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNQUV DGE, IS TRUE AND CORREC <br /> APPLICANTS NAME DATE <br /> (PRINTED 8 SIGNATURE) 1 <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BEOW 1Z:Z4 <br /> OUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# JI cl VI I 1%�� <br /> PERMITNUMBER P RM ITAPPROVED B /DATE PERMIT TION DAT1 61E <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. 1" <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 9� <br /> FORM B (12.91) FOROMR-R6 <br />